Liability insurer and health plan data exchange

ABSTRACT

A data information exchange, which accesses data from liability insurers and health plans, manages the data and allows health plans to identify when their plan participants are third party claimants in injury claims. In another aspect, subrogation entities access the data information exchange in order to perform subrogation operations for the health plans, relating to the health plan&#39;s participants. In another aspect, coordination of benefit recovery entities access the data information exchange in order to perform recovery operations for the health plans, relating to health providers which rendered services to participants of the health plans.

RELATED U.S. APPLICATION DATA

This application is a continuation of U.S. patent application Ser. No.13/031,675, filed Feb. 22, 2011, which claims the benefit of U.S.Provisional Application No. 61/425,360, filed on Dec. 21, 2010. All ofthe foregoing are incorporated by reference in their entireties.

BACKGROUND

Health plans use of number of cost containment tools in their dailyoperations, including TPL (third party liability) identification,coordination of benefits (COB) and subrogation.

The first tool is known as TPL identification. This is when a healthplan including its contracted vendors utilize health claims data andother plan participant information to determine if the participant is athird party claimant in an injury claim, and if the participant receiveda settlement from an insurer or defendant.

Identifying TPL cases is highly dependent on a number of factors, whichtraditionally make it more of a best guess than a knowledge-basedoperation. Generally, it consists of two parts.

First, health plans and their vendors frequently data mine submittedhealth provider claims, looking for particular diagnosis and procedurecodes, which have a possibility of indicating an accident or injurysituation relating to the provider services rendered to the planparticipant.

The provider claim data does indicate when the individual receiving carehas sought health care services as a result of an auto accident,work-related injury or “other accident”. However, these choices do notnecessarily indicate fault, nor do they indicate whether or not thehealth plan's participant has or will file an injury claim against aresponsible party.

Additionally, many types of injury claims, such as those relating toprofessional and product liability, as well as wrongful death, aregenerally not well identified by health claims data alone.

Many injury claims are settled without going to court; therefore, suchinformation is kept privately between claimant, their attorney and theresponsible party, which is typically a liability insurer of self-paydefendant.

The second part in identifying TPL situations is when health plans andvendors, upon establishing a reasonable “hunch” from the data minedclaim information, send out generic accident questionnaires to theirselected plan participants.

These form letters rely squarely on the plan participant to admit tohaving an injury where another party was involved, as well as volunteertheir choice to be involved in an injury claim. Once answeredaccurately, these questionnaires are sent back to the health plan or itsvendor, thereby allowing the plan to stake a financial claim to aportion of monies paid from an injury claim settlement, to the planparticipant.

Such surveys are notoriously ineffective because participants can answer“no” when asked if a third party was involved because they believe thatanswering “yes” could lead to an investigation or further involvement ontheir part.

If an injury claim is accurately identified by the participant'sresponse, the second tool a health plan uses is a follow-up action knownas health care subrogation. This is the health plan's right to pursueany course of action, in its own name or the name of its self-insuredclient, against a third party who is liable for a loss which has beenpaid by the plan. If a settlement. has been paid by the health plan tothe participant, the health plan stakes a subrogation claim against theparticipant directly.

A third tool is also a follow-up action to TPL identification; it isknown as Coordination of Benefits (COB). COB is used by health plans tohalt and if necessary, recover current health claim payments fromcontracted health care providers, when such claim payments have been orare related to a TPL circumstance.

Additionally, subrogation and COB have time factors, where the sooner aplan knows about a TPL applicable to its plan participant, the betterchance it may have to recover its full stake of overpaid monies owed.For this reason, accuracy plus speed are vital components ofidentification and cost containment operations.

These and other known drawbacks exist in the area of third partyliability (TPL) identification and related cost containment operations.

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

The embodiments will become more readily appreciated as the same becomebetter understood by reference to the following illustrations:

FIG. 1 is a schematic block diagram illustrating one of the embodiments,where liability insurers supply third party claimant data through acomputer-based data exchange and to health plans of claimants.

FIG. 2 is a flow diagram expanding the ‘compare and match’ operation ofthe ‘information exchange’ portion in the embodiment.

FIG. 3 is a schematic block diagram illustrating another of theembodiments, where health plans assign their cost containmentoperations, relating to recovery from their plan participants, torecovery entities.

FIG. 4 is a schematic block diagram illustrating an example of anotherembodiment, where health plans assign their cost containment operations,relating to recovery from health providers, to Coordination of Benefit(COB) recovery entities.

FIG. 5 is a variation relating to one of the embodiments, where healthplans, for consideration and value, agree to make payments to theinformation exchange, in order to receive matched data.

DETAILED DESCRIPTION OF SEVERAL EMBODIMENTS

Embodiments of the present invention relate to a computer-basedinformation exchange, which may receive data records from both aliability insurer and a health plan, stores the data, compares both setsof data records to each other, may create a matched data record thatidentifies an individual as both a third party claimant and aparticipant of the health plan, and thereafter, may distribute thematched data to the health plan. The system and process have severalembodiments, where the matched data may be distributed to the healthplan.

One embodiment illustrates the matched data distributed to the healthplan for no consideration or value.

Another embodiment illustrates the matched data distributed to thehealth plan, after the health plan agrees to assign cost containmentoperations, relating to its plan participants within the matched data toa recovery entity, wherein the recovery entity may have a financialrelationship to the computer-based information exchange.

Another embodiment illustrates the matched data distributed to thehealth plan, after the health plan agrees to assign cost containmentoperations, relating to those health providers that furnished servicesto the health plan's participants within the matched data to a recoveryentity, wherein the recovery entity may have a financial relationship tothe computer-based information exchange.

Another embodiment illustrates the matched data distributed to thehealth plan, after the health plan may agree to pay a fee to thecomputer-based information exchange, where the fee relates to the valueof the matched data.

In FIG. 1, an illustration related to one of the embodiments illustratesthird party claimants 101 who submit injury claims 102 to liabilityinsurers 103, where the liability insurers represent defendant partieshaving causal relationships to the third party claimants' injuries.

After receiving the third party claimants' injury claims, the liabilityinsurers 103 create injured claimant data records 104, which may consistof the third party claimants' first names, last names, dates of birthsocial security numbers, home addresses, dates of injuries and thenames, addresses, phone and fax numbers of applicable attorneys, whichrepresent the third party claimants.

In 105, the liability insurers submit injured claimant data records to acomputer-based information exchange 106. The injured claimant datarecords may be in a flat file format, such as Excel® or .CSV files, butthe file format may not necessarily be limited as such.

The computer-based information exchange 106 may be comprised of aserver, personal computer, or other computing device capable ofexecuting software applications. As a non-limiting illustrative example,the computer-based information exchange 106 may comprise a server orgroup of servers, which may be or include, for instance, a workstationrunning Microsoft Windows™ NT™, Microsoft Windows™ 2000, Unix, Linux,Xenix, IBM, AIX™, Hewlett-Packard UX™, Novell Netware™, Sun MicrosystemsSolaris™, OS/2™, BeOS™, Mach, Apache, OpenStep™, or other operatingsystem or platform.

The injured claimant data records sent in 105 may be accepted by andstored within the information exchange's database. The injured claimantdata records may be added to other injured claimant data records fromthe same and other liability insurers.

The database of the information exchange may be or include, for instancean Oracle” relational database sold commercially by Oracle Corporation.Other databases, such as Informix™, D82 (Database 2) or other datastorage or query formats, platforms, or resources such as OLAP (On LineAnalytical Processing), SQL (Standard Query Language), a SAN (storagearea network), Microsoft Access™ or others may also be used,incorporated, or accessed into the computer-based information exchangeof 106.

Health plans 107 create plan participant data records 108, which mayconsist of the plan participants' first names, last names, dates ofbirth, social security numbers and home addresses.

In 109, health plans 107 may perform searches for their planparticipants, who are also third party claimants stored in thecomputer-based information exchange 106. The health plans may search bysubmitting the plan participant data records 108 to the computer-basedinformation exchange 106. The plan participant data records may be in aflat file format, such as Excel® or .CSV files, but the file format maynot be necessarily limited as such.

In 110 the computer-based information exchange may compare commonheadings and data entries of the plan participant data records receivedin 109 to all the existing, stored injured claimant data records it hasin its database.

When there are matches between common headings and data of both recordtypes, the computer-based information exchange in 111 may create matcheddata records. The matched data records may contain the common firstnames, last names, dates of birth, social security numbers and homeaddresses of individuals who are both third party claimants andparticipants of the health plans.

Also included in the matched data records of 111 may be individuals'injury dates and if applicable, the names, addresses, phone and faxnumbers of attorneys representing the third party claimants.

In 112, the health plans 107 may download the matched data records 111from the computer-based information exchange 106.

In FIG. 2, the compare and match function of the computer-basedinformation exchange. 110 of FIG. 1 is shown in an exploded view,demonstrating the compare and match function, common in all of theembodiments.

Within the compare and match function 110, the injured claimant datarecords 104 may consist of the third party claimants' first names 141,last names 142, dates of birth 143, social security numbers 144, homeaddresses 145, dates of injuries 146 and the name, address, phone andfax numbers of any applicable attorneys, which represent the third partyclaimants 147.

Also within the compare and match function 110, the plan participantdata records 108 may consist of the plan participants' first names 151,last names 152, dates of birth 153, social security numbers 154 and homeaddresses 155.

In 148 both the injured claimant and plan participant data records arecompared to each other. When there is a match between common headingsand data of both record types 149, there is matched data record 111created.

The matched data records may contain the common first names 161, lastnames 162, dates of birth 163, social security numbers 164 and homeaddresses 165 of individuals who are both a third party claimant and aparticipant of the health plan.

Also included in the matched data records of 111 may be the individuals'injury dates 166 and if applicable, the representing attorney's name,address, phone and fax numbers 167.

In FIG. 3, another embodiment illustrates third party claimants 301 whosubmit injury claims 302 to liability insurers 303, where the liabilityinsurers may represent defendant parties having causal relationships toinjuries sustained by third party claimants.

After receiving the third party claimants' injury claims, the liabilityinsurers 303 create injured claimant data records 304, which may consistof the third party claimants' first names, last names, dates of birthsocial security numbers, home addresses, dates of injuries and thenames, addresses, phone and fax numbers of applicable attorneys, whichrepresent the third party claimants.

In 305, the liability insurers submit the injured claimant data recordsto a computer-based information exchange 306. The injured claimant datarecords may be in a flat file format, such as Excel® or .CSV files, butthe file format may not necessarily be limited as such.

The computer-based information exchange 306 may be comprised of aserver, personal computer, or other computing device capable ofexecuting software applications. As a non-limiting illustrative example,the computer-based information exchange 306 may comprise a server orgroup of servers, which may be or include, for instance, a workstationrunning Microsoft Windows™ NT™, Microsoft Windows™2000, Unix, Linux,Xenix, IBM, AIX™, Hewlett-Packard UX™, Novell Netware™, Sun MicrosystemsSolaris™, OS/2™, BeOS™, Mach, Apache, OpenStep™, or other operatingsystem or platform.

The injured claimant data records sent in 305 may be accepted by andstored within the information exchange's database. The injured claimantdata records may be added to other injured claimant data records fromthe same and other liability insurers.

The database of the information exchange may be or include, for instancean Oracle™ relational database sold commercially by Oracle Corporation.Other databases, such as Informix™ DB2 (Database 2) or other datastorage or query formats, platforms, or resources such as OLAP (On LineAnalytical Processing), SQL (Standard Query Language), a SAN (storagearea network), Microsoft Access™ or others may also be used,incorporated, or accessed into the computer-based information exchangeof 306.

Health plans 307 create plan participant data records 308, which mayconsist of the plan participants' first names, last names, dates ofbirth, social security numbers and home addresses.

In 309, the health plans 307 may search for any their plan participants,who are also third party claimants stored in the computer-basedinformation exchange 306. The health plans may search by submitting planparticipant data records 308 to the computer-based information exchange306. The plan participant data records may be in a flat file format,such as Excel® or .CSV files, but the file format may not necessarily belimited as such.

In 310 the computer-based information exchange may compare commonheadings and data entries of plan participant data records received in309 to all the existing, stored injured claimant data records it has inits database.

When there are matches between common headings and data of both injuredclaimant and plan participant data records, the computer-basedinformation exchange in 311 may create matched data records. The matcheddata records may contain the common first names, last names, dates ofbirth, social security numbers and home addresses of individuals who areboth third party claimants and participants of the health plans.

Also included in the matched data records of 311 may be the individuals'injury dates and if applicable, the representing attorneys' names,addresses, phone and fax numbers.

In 312, the computer-based information exchange may submit the number ofindividuals within the matched data records 311, but may not reveal anyidentifying information in the matched data records to the health plans307.

In 313, the health plans 307 may agree to assign subrogation operations,relating to their plan participants within the matched data records 311to recovery entities providing health plan subrogation services(“subrogation entity”) 315. The subrogation entities may have afinancial relationship to the computer-based information exchange 306.

After the health plans agree to assign subrogation services, in 314 thecomputer-based information exchange 306 may submit the matched datarecords and the names of third party claimants' health plans 307 to thesubrogation entities 315.

In 316, the health plans 307 may download the matched data records 311and the names of the subrogation entities 315 assigned to handle thesubrogation operations pertaining to the health plans' participantswithin the matched data records, wherein the downloads come from thecomputer-based information exchange 3-6.

In 317, the subrogation entities 315 may contact the health plans 307;the health plans share health claim data with the subrogation entities,relevant to the health plans' participants and dates of the planparticipants' injuries in the matched claim records 311.

Thereafter, in 318, the subrogation entities 315 may contact the thirdparty claimants 301, who are also plan participants of the health plans307. Later, in 319 the third party claimants 301 pay on subrogationclaims, the payments made to the subrogation entities 315.

After subrogation monies have been collected, in 320 the subrogationentities 315 may make portioned payments to the health plans 307. Aftersuch payments to the health plans, the subrogation entities may keep aportion of remaining subrogation monies, remitting the remaining moniesthereafter, through fee payments 321 to the computer-based informationexchange 306.

At this time, the liability insurers 303 may be permitted to performstatus checks 322 on the third party claimants within the injuredclaimant data records 304 that the liability insurers submitted to thecomputer-based information exchange in 305.

In response to the status checks 322, the computer-based informationexchange 306 sends the liability insurers 303 back status responses 323.

In 324, after the computer-based information exchange 306 receives itsfee 321 from subrogation entities 315, the computer-based informationexchange may remit a portion of its fee payments to the liabilityinsurers 303.

In FIG. 4, another embodiment illustrates third party claimants 401 whomay submit injury claims 402 to liability insurers 403, where theliability insurers represent defendant parties having causalrelationships to injuries sustained by third party claimants.

After receiving the third party claimants' injury claims, the liabilityinsurers 403 may create injured claimant data records 404, which mayconsist of the third party claimants' first names, last names, dates ofbirth social security numbers, home addresses, dates of injuries and thenames, addresses, phone and fax numbers of applicable attorneys, whichrepresent the third party claimants.

In 405, the liability insurers may submit the injured claimant datarecords to a computer-based information exchange 406. The injuredclaimant data records may be in a flat file format, such as Excel® or.CSV files, but the file format may not necessarily be limited as such.

The computer-based information exchange 406 may be comprised of aserver, personal computer, or other computing device capable ofexecuting software applications. As a non-limiting illustrative example,the computer-based information exchange 406 may comprise a server orgroup of servers, which may be or include, for instance, a workstationrunning Microsoft Windows™ NT™, Microsoft Windows™ 2000, Unix, Linux,Xenix, IBM, AIX™, Hewlett-Packard UX™, Novell Netware™, Sun MicrosystemsSolaris™, OS/2™, BeOS™, Mach, Apache, OpenStep™, or other operatingsystem or platform.

The injured claimant data records sent in 405 may be accepted by andstored within the information exchange's database. The injured claimantdata records may be added to other injured claimant data records fromthe same and other liability insurers.

The database of the information exchange may be or include, for instancean Oracle™ relational database sold commercially by Oracle Corporation.Other databases, such as Informix™, DB2 (Database 2) or other datastorage or query formats, platforms, or resources such as OLAP (On LineAnalytical Processing), SQL (Standard Query Language), a SAN (storagearea network), Microsoft Access™ or others may also be used,incorporated, or accessed into the computer-based information exchangeof 406.

Health plans 407 create plan participant data records 408, consisting ofthe plan participants' first names, last names, dates of birth, socialsecurity numbers and home addresses.

In 409, the health plans 407 search for any their plan participants, whoare also third party claimants stored in the computer-based informationexchange 406. The health plans search by submitting plan participantdata records 408 to the computer-based information exchange 406. Theplan participant data records may be in a flat file format, such asExcel® or .CSV files, but the file format may not be necessarily limitedas such.

410 the computer-based information exchange may compare common headingsand data entries of plan participant data records received in 409 to allthe existing, stored injured claimant data records it has in itsdatabase.

When there are matches between common headings and data of both injuredclaimant and plan participant data records, the computer-basedinformation exchange in 411 may create matched data records. The matcheddata records may contain the common first names, last names, dates ofbirth, social security numbers and home addresses of individuals who areboth third party claimants and participants of the health plans.

Also included in the matched data records of 411 may be the individuals'injury dates and if applicable, the representing attorneys', names,addresses, phone and fax numbers.

In 412, the computer-based information exchange submits the number ofindividuals within the matched data records 411, but may not reveal anyidentifying information in the matched data records to the health plans407.

In 413, the health plans 407 may agree to assign (Coordination ofBenefits) COB recovery operations, relating to the health providers 419who provided services to the health plans' participants within thematched data records 411 to recovery entities providing COB services(“COB recovery entities”) 415. The COB recovery entities may have afinancial relationship to the computer-based information exchange 406.

After the health plans agree to assign the COB recovery services, in 414the computer-based information exchange 406 may submit the matched datarecords and the names of the third party claimants' health plans to theCOB recovery entities 415.

In 416, the health plans 407 may download the matched data records 411and the names of the COB recover entities 415 assigned to handle the COBrecovery operations pertaining to the health plans' participants withinthe matched data records, wherein the downloads come from thecomputer-based information exchange 406.

In 417, the COB recovery entities 415 may contact the health plans 407;the health plans may share health claim data with the COB recoveryentities, including the names of the health providers 419 who renderedcare to the plan participants, relevant to the dates of the planparticipants' injuries in the matched claim records 411.

Thereafter, in 418, the COB recovery entities 415 may contact therendering health care providers 419. Later, in 420 the health providers419 may pay on COB recovery claims to the COB recovery entities 415.

After COB recovery monies have been collected, in 421 the COB recoveryentities 415 may make portioned payments to the health plans 407. Aftersuch payments to the health plans, the COB recovery entities may keepportions of remaining COB recovery monies, remitting the remainingmonies thereafter, through fee payments 422 to the computer-basedinformation exchange 406.

At this time, the liability insurers 403 may be permitted to performstatus checks 423 on the third party claimants within the injuredclaimant data records 404, submitted by the liability insurers to thecomputer-based information exchange in 405.

In response to the status checks 423, the computer-based informationexchange 406 sends the liability insurers 403 back status responses 424.

In 425, after the computer-based information exchange 406 receives fees422 from COB recovery entities 415, the computer-based informationexchange may remit portions of its fee payments to the liabilityinsurers 403.

In FIG. 5, an illustration related to one of the embodiments illustratesthird party claimants 501 who may submit injury claims 502 to liabilityinsurers 503, where the liability insurers may represent defendantparties having causal relationships to the third party claimants'injuries.

After receiving the third party claimants' injury claims, the liabilityinsurers 503 may create injured claimant data records 504, which mayconsist of the third party claimants' first names, last names, dates ofbirth social security numbers, home addresses, dates of injuries and thenames, addresses, phone and fax numbers of applicable attorneys, whichrepresent the third party claimants.

In 505, the liability insurers may submit injured claimant data recordsto a computer-based information exchange 506. The injured claimant datarecords may be in a flat file format, such as Excel® or .CSV files, butthe file format may not necessarily be limited as such.

The computer-based information exchange 506 may be comprised of aserver, personal computer, or other computing device capable ofexecuting software applications. As a non-limiting illustrative example,the computer-based information exchange 506 may comprise a server orgroup of servers, which may be or include, for instance, a workstationrunning Microsoft Windows™ NT™, Microsoft Windows™ 2000, Unix, Linux,Xenix, IBM, AIX™, Hewlett-Packard UX™, Novell Netware™, Sun MicrosystemsSolaris™, OS/2™, BeOS™, Mach, Apache, OpenStep™, or other operatingsystem or platform.

The injured claimant data records sent in 505 may be accepted by andstored within the information exchange's database. The injured claimantdata records may be added to other injured claimant data records fromthe same and other liability insurers.

The database of the information exchange may be or include, for instancean Oracle™ relational database sold commercially by Oracle Corporation.Other databases, such as Informix™, DB2 (Database 2) or other datastorage or query formats, platforms, or resources such as OLAP (On LineAnalytical Processing), SQL (Standard Query Language), a SAN (storagearea network), Microsoft Access™ or others may also be used,incorporated, or accessed into the computer-based information exchangeof 506.

Health plans 507 may create plan participant data records 508 consistingof the plan participants' first names, last names, dates of birth,social security numbers and home addresses.

In 509, health plans 507 may perform searches for their planparticipants, who are also third party claimants stored in thecomputer-based information exchange 506. The health plans search bysubmitting the plan participant data records 508 to the computer-basedinformation exchange 506. The plan participant data records may be in aflat file format, such as Excel® or .CSV files, but the file format maynot necessarily be limited as such.

In 510 the computer-based information exchange may compare commonheadings and data entries of the plan participant data records receivedin 509 to all the existing, stored injured claimant data records it hasin its database.

When there are matches between common headings and data of both recordtypes, the computer-based information exchange in 511 creates matcheddata records. The matched data records may contain the common firstnames, last names, dates of birth, social security numbers and homeaddresses of individuals who are both third party claimants andparticipants of the health plans.

Also included in the matched data records of 511 may be individuals'injury dates and if applicable, the names, addresses, phone and faxnumbers of attorneys representing the third party claimants.

In 512, the computer-based information exchange may submit the number ofindividuals within the matched data records 511, but may not reveal anyidentifying information in the matched data records to the health plans507.

In 513, the health plan 507 agrees to pay the computer-based informationexchange 506 a fee in exchange for the health plan downloading matcheddata record 511.

Thereafter, in 514 the health plan 507 downloads the matched data record511 from the computer-based information exchange 506. Later, in 515, thehealth plan 507 may pay the computer-based information exchange 506, inconsideration for the downloaded data, as agreed upon in 513.

At this time, the liability insurer 503 may be permitted to perform astatus check 516 on the third party claimants within the injuredclaimant data record 504 it submitted to the computer-based informationexchange in 505.

In response to the status check 516, the computer-based informationexchange 506 sends the liability insurer 503 back a status response 517.

In 518, after the computer-based information exchange 506 receives itsfee 515 from health plan 507, the computer-based information exchangemay remit a portion of its fee payment to the liability insurer 503.

Similarly, it is envisioned that singular elements may also beinterpreted as one or more.

What is claimed is:
 1. A non-transitory tangible computer readablemedium containing a series of instructions, which when executed by oneor more processors, causes the one or more processors to perform aninformation exchange process comprising: i) comparing injured claimantdata records and plan participant data records, the injured claimantdata records containing identifying demographic information about thirdparty claimants, the injured claimant data records created by liabilityinsurers after receiving injury claims from third party claimants, theplan participant data records containing identifying demographicinformation about participants of health plans, the plan participantdata records created by the health plans; and ii) creating matched datarecords by identifying a match of information shared between injuredclaimant data records and plan participant data records, the matchindicating individuals who are both third party claimants andparticipants of the health plans.